Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Perry Lutheran Home during CMS and state inspections, most recent first.
Hand Hygiene Not Performed During Meal Assistance: A CNA assisted a resident with lunch and used a fork to feed the resident without completing hand hygiene before the meal. The CNA acknowledged not washing hands before assisting the resident, and the DON stated staff were expected to perform hand hygiene before and after helping a resident with meals. The facility policy required handwashing before and after resident contact and before handling food.
Failure to use EBP during catheter care for a resident with an indwelling urinary catheter. The resident’s care plan required EBP, but a CNA entered the room, washed hands, and used gloves only while cleansing the catheter bag drain tube and emptying the urine bag. The CNA stated a gown, face mask, and gloves were required for residents on EBP, and the IP stated gown and gloves were expected for high-contact care, including catheter care.
Failure to offer and document COVID-19 vaccination for eligible residents. Three residents with significant cognitive impairment and diagnoses including dementia, Alzheimer's disease, diabetes, and HTN were not up to date with COVID-19 vaccination. Records showed POA consent forms for some residents, but the EHR lacked documented COVID-19 vaccine administration, progress note evidence of receipt, care plan documentation, and in one case a clear POA response on the consent form. Physician orders addressed flu vaccine only and did not include a COVID-19 vaccination order.
Staff failed to follow infection control and hand hygiene protocols during peri care for a resident with severe cognitive impairment and multiple diagnoses. Two CNAs performed hand hygiene once before donning gloves and enhanced barrier precautions, then removed soiled clothing and briefs, cleansed the perineal and buttock areas, changed the brief and bed pad, pulled up the resident’s pants, applied a mechanical lift sling, transferred the resident to a wheelchair, and completed grooming tasks without changing gloves and performing hand hygiene at the intervals required by the facility’s peri care protocol. The DON stated she expected staff to change gloves and perform hand hygiene during peri care, and one CNA acknowledged she had not done so.
A resident with diabetes and other complex conditions experienced a severe hypoglycemic episode after staff failed to complete scheduled blood glucose checks and medication administration. Nursing staff did not follow hypoglycemia protocols, did not provide immediate intervention, and delayed calling emergency services. The resident was found unresponsive by a family member, and emergency responders administered Glucagon, resulting in the resident regaining consciousness. Previous low blood sugar episodes were also not properly documented or addressed.
Staff failed to follow infection control protocols by not performing hand hygiene between medication administrations, not properly disinfecting a shared glucose machine, and not using required PPE or changing gloves during catheter and perineal care for a resident with multiple medical conditions. These actions were inconsistent with facility policies and staff expectations.
A resident with dementia and moderate cognitive impairment experienced three falls, and the facility failed to implement and document timely, specific fall prevention interventions after each incident. Interventions such as lab work, use of gripper socks, and physical therapy referrals were either delayed, not documented in the care plan, or not fully implemented according to facility policy.
A medication cart containing a bubble packet of Olanzapine was left unlocked and unattended in a hallway near the dining room on the CCDI unit, with three residents observed near the cart and no nursing staff present. An LPN later confirmed the cart should not have been left unlocked or medications left unattended, in accordance with facility policy.
A cook failed to follow proper glove use during food preparation, using the same gloves to handle multiple items including bread, a peanut butter jar, and a hotdog package without changing gloves between tasks. Facility policy requires gloves to be changed between tasks and recommends using utensils like tongs for ready-to-eat foods. The Dietary Manager confirmed these expectations.
A resident with a history of COPD and other conditions was not sent to the ER despite significant changes in their condition, including neurological decline and respiratory distress. The facility failed to notify the physician as required, leading to the resident's hospitalization for hypoxemia, bronchopneumonia, and dehydration.
A resident with multiple disabilities required substantial assistance for daily activities. During a transfer, a CNA used excessive force and profanity, causing the resident discomfort. Other staff and residents corroborated the CNA's rough behavior. The CNA was suspended and later terminated.
The facility failed to ensure comfortable positioning and securement of safety straps when using a mechanical lift device for two residents. One resident experienced pain and instability during the transfer, while another had her arm improperly positioned and the safety buckle not tightened. The facility's training materials lacked specific instructions for securing the waist belt.
A facility failed to accurately account for administered and destroyed narcotic medication for a resident with fractures and muscle weakness. The resident was prescribed tramadol, but discrepancies were found between the Controlled Medication Utilization Record and the electronic MAR. The facility's policy required co-counting and documentation of unused narcotics, but staff failed to enter the total number of doses destroyed. The DON acknowledged the documentation errors.
The facility failed to provide a bed hold notice upon hospitalization for two residents. One resident with severe cognitive impairment and multiple diagnoses was discharged to the hospital for a fractured hip, and another resident with intact cognition and multiple diagnoses was discharged for a fractured left ankle. The clinical records lacked documentation of bed hold notices for both residents, and the DON confirmed that no bed hold forms were completed.
Hand Hygiene Not Performed During Meal Assistance
Penalty
Summary
The facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal service. On 4/1/26 at 11:20 AM, an observation showed Staff C, a CNA, assisting a resident seated at a lunch room table, then walking to another resident who attempted to stand up, explaining he would assist the resident in eating lunch, sitting next to the resident, and using a fork to assist the resident with bites of food without completing hand hygiene. Later that day, Staff C stated that Resident #2 required assistance with lunch and acknowledged that he did not complete hand hygiene before assisting Resident #2 with the meal. On 4/2/26 at 11:30 AM, the Administrator stated she expected staff assisting a resident with any meal to complete hand hygiene before and after assisting the resident. The facility policy titled Hand Washing Technique stated that handwashing before and after physical contact with each resident is the single most important means of preventing the spread of infection and that staff should always wash hands before and after physical contact with each resident and before eating, drinking, or handling food.
Failure to Use EBP During Catheter Care
Penalty
Summary
The facility failed to maintain infection control practices to ensure use of Enhanced Barrier Precautions (EBP) during catheter care for Resident #48. The resident’s MDS dated 3/10/26 listed diagnoses of cancer, urinary tract infection in the past 30 days, and retention of urine, and identified an indwelling urinary catheter. The care plan initiated 3/10/26 stated the resident required EBP related to the indwelling catheter. During observation on 3/31/26 at 1:32 PM, Staff B, a CNA, entered the resident’s room with an EBP sign on the door, washed hands, and applied gloves only before cleansing the catheter bag drain tube, emptying the urine from the catheter bag, and cleansing the drain tube again. Staff B then removed gloves and washed hands. During interview, Staff B stated EBP for residents with catheters and wounds required a gown, face mask, and gloves for any cares and stated she should have worn a gown to empty the resident’s catheter bag. The facility’s EBP policy dated 3/2026 stated EBP is targeted gown and glove use during high contact resident care activities and will be implemented for residents with urinary catheters. The Infection Preventionist stated staff were expected to wear a gown and gloves when providing any high contact care for residents on EBP, including catheter care.
Failure to Offer and Document COVID-19 Vaccination for Eligible Residents
Penalty
Summary
The facility failed to offer and provide the recommended COVID-19 vaccine to eligible residents for 3 of 5 residents reviewed for vaccines. Resident #2 had severely impaired cognition with a BIMS score of 00 out of 15 and diagnoses including diabetes mellitus, non-Alzheimer's dementia, and hypertension. The record showed the resident was not up to date with COVID-19 vaccination, and although the EHR contained a consent form indicating the POA consented to yearly COVID-19 booster vaccination, there was no documented COVID-19 vaccination after 10/07/24 in the immunization record, no progress note documenting receipt of the vaccine, and no vaccination documented in the care plan. The physician order dated 10/09/25 addressed annual flu vaccine only and did not include a COVID-19 vaccination order. Resident #35 had a BIMS score of 07 out of 15 with diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and hypertension, and was also not up to date with COVID-19 vaccination. The EHR contained a vaccine consent form for influenza, pneumonia, and COVID vaccine, but it did not indicate a verbal response from the resident's POA. Resident #38 had a BIMS score of 00 out of 15 with diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and hypertension, and was not up to date with COVID-19 vaccination. The EHR showed POA consent for yearly COVID-19 booster vaccination, but there was no documented COVID-19 vaccination after 10/07/24, no progress note documenting a booster after 11/07/24, and no vaccination documented in the care plan. The facility's policy required education, opportunity to consent or decline, and documentation of vaccination status for residents not up to date with COVID-19 vaccination.
Failure to Perform Proper Hand Hygiene During Peri Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper hand hygiene during incontinence (peri) care for one resident. The resident had diagnoses including Alzheimer’s disease, arthritis, hip fracture, and depression, with a BIMS score of 00 indicating severe cognitive impairment. During an observation of peri care, two CNAs performed hand hygiene before donning gloves and enhanced barrier precautions, then removed the resident’s pants and soiled brief. One CNA cleansed the front perineal area, and both CNAs then turned the resident to cleanse the back side. One CNA removed the soiled brief and bed pad and placed a clean brief and bed pad under the resident, after which the resident was rolled and the clean brief and pad were put in place. Throughout this process, both CNAs continued to perform multiple care tasks without appropriate glove changes and hand hygiene as outlined in the facility’s peri care audit protocol. After completing cleansing and brief changes, they pulled up the resident’s pants, applied a mechanical lift sling under the resident while still wearing soiled gloves, and only then changed gloves without performing hand hygiene. They then applied new gloves and used the mechanical lift to transfer the resident to a wheelchair, placed leg pedals, a blanket, and combed the resident’s hair, again without changing gloves or performing hand hygiene during these steps. The facility’s peri care audit instructions specified multiple points at which gloves should be removed and hand hygiene performed during peri care, and the DON stated she would expect staff to change gloves and perform hand hygiene while performing peri care. One CNA later acknowledged she should have changed gloves and performed hand hygiene during the peri care process.
Failure to Assess and Intervene for Severe Hypoglycemia
Penalty
Summary
A resident with a history of diabetes, heart failure, renal insufficiency, and other complex conditions experienced a severe hypoglycemic event due to the facility's failure to appropriately assess and intervene. The resident was prescribed multiple diabetic medications, including insulin and Tirzepatide, with scheduled blood glucose checks and medication administration times. On the day of the incident, the scheduled 4:00 PM blood sugar check and administration of insulin and Tirzepatide were not completed within the required window. The nurse coming on duty was informed of the missed tasks but did not immediately assess the resident or complete the overdue interventions. The resident was later found unresponsive by a family member, and a blood sugar check revealed a critically low level of 27 mg/dl. Facility staff failed to follow established protocols for hypoglycemia management. The nurse did not administer a carbohydrate source or call the primary care physician when the resident was found unresponsive with low blood sugar. Additionally, there was no Glucagon available in the medication carts, and the resident did not have an order for Glucagon prior to the event. The nurse spent approximately 15 minutes searching for Glucagon instead of providing immediate intervention, and did not call emergency services as requested by the family. The family member ultimately called 911, and emergency responders administered Glucagon, after which the resident became responsive and was transported to the hospital. Review of the resident's records revealed previous episodes of low blood sugar that were not properly documented or addressed according to facility policy. There was a lack of documentation regarding interventions taken to correct hypoglycemia on multiple occasions, and vital signs were not recorded at the time the resident was found unresponsive. Staff interviews confirmed that the required steps for hypoglycemia management, including timely administration of carbohydrates, notification of the physician, and documentation, were not consistently followed.
Failure to Maintain Infection Control Standards During Resident Care and Medication Administration
Penalty
Summary
Staff failed to maintain infection control standards in several key areas. Certified Medication Aides (CMAs) were observed administering medications to multiple residents without performing hand hygiene before or after each administration, contrary to facility policy and stated expectations. Additionally, a CMA was seen using a multi-resident glucose machine without disinfecting it after use, only wiping it with an alcohol swab instead of following the manufacturer's guidelines for proper disinfection and drying time. The glucose machine was used for multiple residents, increasing the risk of cross-contamination. In another instance, a Certified Nursing Assistant (CNA) did not apply personal protective equipment (PPE) as required by Enhanced Barrier Precautions (EBP) when providing catheter care to a resident with multiple diagnoses, including peripheral vascular disease and an indwelling urinary catheter. The EBP signage was present on the resident's door, and facility policy required gown and glove use for such care activities, but the CNA did not comply, later stating uncertainty about when PPE was necessary. Further observations revealed that two CNAs performed perineal care on a resident without changing gloves or performing hand hygiene at appropriate intervals, despite handling soiled clothing and linens. The facility's peri care protocol specifies glove changes and hand hygiene at multiple steps during the process, but these were not followed. Staff interviews confirmed awareness of the correct procedures but acknowledged lapses during care.
Failure to Implement and Document Timely Fall Interventions
Penalty
Summary
The facility failed to implement timely and specific fall prevention interventions for a resident with a history of falls and multiple risk factors, including non-Alzheimer's dementia, anxiety, depression, hypertension, and moderate cognitive impairment. The resident required substantial to maximal assistance with transfers and dressing. Despite experiencing three separate falls within a short period, interventions were either delayed or not fully implemented according to the facility's own policies and care planning requirements. After the first fall, which occurred while the resident was ambulating with staff and became weak, the only intervention was to perform follow-up lab work to check for infection, which was not completed until several days later. No additional interventions were put in place at that time. Following the second fall, the resident was found on the floor with regular socks, and although staff educated about using gripper socks during nighttime care, this intervention was not documented in the care plan. The only care plan update was to notify the physician about the resident's confusion, but no further interventions were added. The third fall involved the resident being found on the floor, partially wrapped in bedding, again wearing athletic socks. Immediate interventions included placing gripper socks and using rolled blankets as mattress borders, but documentation of these interventions in the care plan was lacking. The facility's policy requires staff to identify, implement, and document resident-specific fall interventions and to monitor and adjust these interventions as needed. However, the facility did not consistently document or implement timely interventions after each fall, and staff education and communication were not adequately recorded.
Unattended and Unlocked Medication Cart with Accessible Medications
Penalty
Summary
A medication cart was observed unlocked and unattended in the main hallway by the dining room on the CCDI (Chronic Confusion or Dementing Illness) unit. On top of the cart was a bubble packet of prescription Olanzapine, an antipsychotic medication, with two pills remaining. The cart was left unattended for approximately four minutes, during which time three residents were observed near the cart, including two who were walking independently and one in a wheelchair. The cart was not visible from the dining room due to a separating wall, and no nursing staff were present during this period. Staff interviews confirmed that the LPN responsible for the cart acknowledged she should not have left the cart unlocked or medications unattended, especially given that residents on the unit are known to take items from the cart. The facility's policy, dated January 2025, requires that the medication cart be kept locked at all times unless in use and within the nurse's sight. The administrator also confirmed the expectation that medication carts remain locked and medications are not left unattended.
Failure to Maintain Sanitary Food Preparation Practices
Penalty
Summary
Staff responsible for food preparation failed to maintain sanitary conditions while handling ready-to-eat foods. During observation, a cook applied gloves after hand hygiene, then used the same gloved hands to untwist a bread sack, open it, remove bread, handle a peanut butter jar and knife, assemble sandwiches, and place them on a plate. The gloves were not changed between these tasks, despite the facility's policy requiring gloves to be changed between tasks and not worn continuously. The cook only removed the gloves and washed hands after completing all these steps. In a separate observation, the same staff member applied a glove to one hand, opened a bag containing a hotdog package, reached into the package with the gloved hand to remove a hotdog, and placed it on a plate before removing the glove and washing hands. The facility's policy specifies that gloves are single-use and must be changed between tasks, and that utensils such as tongs should be used when handling ready-to-eat foods. The Dietary Manager confirmed that staff are expected to prepare supplies, wash hands, and use tongs for such tasks.
Failure to Provide Timely Medical Intervention for Resident
Penalty
Summary
The facility failed to provide necessary services in accordance with professional standards for a resident who experienced a change in their condition. The resident, who had a history of hypertension, non-Alzheimer dementia, anxiety, depression, asthma, and COPD, was not sent to the nearest emergency room when there was a significant change in their assessment. This oversight resulted in the resident being admitted to the hospital with hypoxemia, bronchopneumonia, and dehydration. The resident's care plan, initiated on 8/12/24, included interventions for managing COPD and the risk of respiratory infections. Despite these measures, the resident experienced a fall on 10/9/24, after which they exhibited signs of neurological decline, such as drowsiness, sluggish pupil response, and inability to follow commands. These symptoms persisted, yet the facility staff did not notify the physician of the changes in the resident's neurological status as required by the facility's policy. On 10/11/24, the resident's condition further deteriorated, with symptoms including slurred speech, pale appearance, and erratic heart rate. It was only after these significant changes that the resident was sent to the emergency room, where they were diagnosed with bronchitis related to COPD exacerbation, hypoxemia, and dehydration. The facility's failure to promptly address the resident's change in condition and notify the physician contributed to the resident's hospitalization.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to ensure that all residents are treated with dignity and respect, and free from abuse during resident care tasks for Resident #7. Resident #7, who has cerebral palsy, hemiplegia, seizure disorder, anxiety disorder, and intellectual disabilities, required substantial assistance for daily activities and was dependent for transfers. On 4/22/24, Staff A, a CNA, reported to the Director of Nursing (DON) that Staff B, another CNA, was rough when caring for Resident #7. During a transfer using a mechanical lift, Resident #7 needed to rest and asked to try again, to which Staff B responded with profanity and refused. Staff B then used excessive force to assist the resident into bed, causing the resident to express discomfort and nervous laughter. Staff B was reported to have displayed frustration and rough behavior in front of residents on multiple occasions. Interviews with other staff and residents corroborated the rough and hurried behavior of Staff B. Staff C, an RN on duty, was unaware of the incident but noted that Staff B was frustrated due to a long shift. Resident #8 and Resident #3 also reported instances of Staff B's rough behavior and frustration. The facility's policy on abuse prevention indicated that personal degradation includes willful acts or statements intended to shame, degrade, humiliate, or harm a resident's personal dignity. Following the investigation, Staff B was suspended and later terminated due to discrepancies in her recall of events and reports of her displaying frustration in front of residents.
Failure to Ensure Proper Use of Mechanical Lift Devices
Penalty
Summary
The facility failed to ensure comfortable positioning and securement of safety straps when using a mechanical lift device for two residents. Resident #22, who had a history of cerebrovascular accident, aphasia, and hemiplegia, was observed being transferred with an EZ Stand by two CNAs. During the transfer, the resident's right arm was stuck between the handle of the wheelchair and the padded cushion, causing him pain. Additionally, the staff did not lock the wheels of the lift, and the resident was not holding onto the handles, causing instability. The staff also failed to tighten the buckle around the resident's torso while he was in a standing position, compromising his safety during the transfer process. Similarly, Resident #30, who had diagnoses including a displaced intertrochanteric fracture of the left femur, muscle weakness, and severe cognitive impairment, was also transferred using the EZ Stand by two CNAs. During the transfer, the resident's right arm was positioned under the sling, and the staff failed to tighten the buckle around her torso both when she was raised to a standing position and after she was moved to the toilet. The facility's Director of Nursing acknowledged that their training materials lacked specific instructions to tighten the waist belt once the resident was standing, which contributed to the improper use of the mechanical lift device.
Discrepancy in Narcotic Medication Documentation
Penalty
Summary
The facility failed to accurately account for administered and destroyed narcotic medication for a resident, leading to a deficiency in pharmaceutical services. The resident, who had a left femur fracture, a fracture of the right foot, and muscle weakness, required substantial assistance with transferring and experienced frequent pain. The resident was prescribed tramadol 50 mg, 1 and 1/2 tablets every 6 hours as needed for pain. However, discrepancies were found between the Controlled Medication Utilization Record and the electronic Medication Administration Record (MAR). The Controlled Medication Utilization Record indicated that the medication was administered on specific dates and times, with a remaining amount of 9 doses, but the MAR showed only one 50 mg tablet was given during the entire stay. The facility's policy on medication management required that unused narcotics be co-counted by two nurses, destroyed, documented on the narcotic record, and noted in the nurses' notes. However, the documentation of the destruction of the remaining narcotics was incomplete, as staff failed to enter the total number of doses destroyed. The Director of Nursing acknowledged that the disposal documentation should have indicated the total number of pills destroyed and that the MAR documentation should have matched the Controlled Medication Utilization Record.
Failure to Provide Bed Hold Notice Upon Hospitalization
Penalty
Summary
The facility failed to provide a bed hold notice upon hospitalization for two residents. Resident #38, who had severe cognitive impairment and multiple diagnoses including coronary artery disease and Alzheimer's disease, was discharged to the hospital for a fractured hip. The clinical record lacked documentation that a bed hold notice was provided to Resident #38 or their representative. The Director of Nursing (DON) confirmed that no bed hold form was completed for this resident, despite it being an expectation for nurses to do so when sending someone to the hospital. Similarly, Resident #114, who had intact cognition and multiple diagnoses including coronary artery disease and chronic obstructive pulmonary disease, was discharged to the hospital for a fractured left ankle. The clinical record also lacked documentation of a bed hold notice for this resident. The DON acknowledged that a bed hold notice was not completed for Resident #114. The facility's policy requires that a written bed hold notice be provided to the resident or their representative prior to or upon transfer to a hospital, or within 24 hours in case of an emergency, but this was not adhered to in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Perry
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Of Perry | 0.3 mi | ★★★★★ | 15 | 0 |
| Perry Lutheran Homes Eden Acres Campus | 0.8 mi | ★★★★★ | 3 | 0 |
| Spurgeon Manor | 12.9 mi | ★★★★★ | 4 | 0 |
| Madrid Home For The Aged | 13.9 mi | ★★★★★ | 7 | 0 |
| Accura Healthcare Of Ogden, Llc | 14.2 mi | ★★★★★ | 11 | 0 |
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